1、10/6/2018,麻疹,1,第十章感染性疾病 病毒感染-麻 疹,Measles,蚌埠医学院附属医院儿科 董淮富,10/6/2018,麻疹,2,目的要求,熟悉麻疹的病因、流行病学及发病机制 掌握麻疹早期诊断要点及典型临床经过 熟悉其它类型麻疹的临床表现 熟悉麻疹常见并发症 掌握麻疹与其它发疹性传染病的鉴别要点 掌握麻疹的防治原则及方法,10/6/2018,麻疹,3,概 述(overview),麻疹是一种由麻疹病毒引起的急性呼吸道传染病(Measles is an acute respiratory contagious disease caused by measles virus ),10/
2、6/2018,麻疹,4,概 述(overview),临床特征为：发热、上呼吸道炎症、结合膜炎、Koplik斑及全身性斑丘疹(clinical features: fever,upper respiratory inflammation, conjunctivitis, Kopliks spots and generalized maculopapular rash),10/6/2018,麻疹,5,病 原(ETIOLOGY),麻疹病毒(measles virus) 属副粘液病毒，无亚型，仅一种抗原型( RNA-containing virus of the Paramyxovirus famil
3、y ,only one serotype),10/6/2018,麻疹,6,病 原(ETIOLOGY),麻疹病毒(measles virus) 麻疹病毒不耐热，对日光和消毒剂均敏感，但在低温中能长期保存(Measles virus are rapidly inactivated by heat,light , and all kinds of desinfectant,but can be stored indefinitely at low temperature)。,10/6/2018,麻疹,7,病 原(ETIOLOGY),麻疹病毒(measles virus) 存在于患者前驱期和出疹期的眼
4、结膜、鼻、咽、气管等分泌物中(During the prodromal period and eruption period,it is found in sections of conjunctiva, nose , pharynx ,trachea and so on)。,10/6/2018,麻疹,8,麻疹的发病机制,鼻、咽 短期繁殖 病毒 局部粘膜 血流 远处器官单核眼结膜 （第一次） 巨噬细胞系统潜伏期 大量繁殖 局部症状 血流 （第二次） 前驱期 全身症状,10/6/2018,麻疹,9,病理(PATHOGEY),全身淋巴组织增生，有多核巨细胞形成(Hyperplasia of all
5、 lymphoid tissue usually occurs,multinucleated giant cells may be found ),10/6/2018,麻疹,10,病理(PATHOGEY),多核巨细胞(multinucleated giant cells)：多个巨噬细胞融合形成的具有核内外包涵体的巨细胞 网状内皮巨细胞也称华-佛细胞（reticuloendothelial giant cells or Warthin-Finkeldey cells)：存在于全身淋巴组织和肝、脾等脏器中 上皮巨细胞（epithelial giant cells）：主要位于皮肤、眼结合膜、呼吸道和
6、消化道粘膜等处,10/6/2018,麻疹,11,病理(PATHOGEY),皮肤、眼结合膜、鼻咽部、支气管、肠道粘膜等处可见单核细胞增生及围绕在毛细血管周围的多核巨细胞，淋巴样组织肥大(Prolifieration of mononuclear cells is found in the skin,in the conjunctivae and in the mucous membranes of the nasopharynx, bronchi, and intestinal tract,multinucleated giant cells occur around the capillari
7、es. Hyperplasia of lymphoid tissue occurs.),10/6/2018,麻疹,12,病理(PATHOGEY),颊粘膜下层的微小分泌腺发炎，其病变内有浆液渗出及内皮细胞增殖形成Koplik斑(An inflammatory reaction occurs in the fine secretor of the buccal mucosa, where serous exudate and proliferation of endothelial cells result in Kopliks spots),10/6/2018,麻疹,13,病理(PATHOGEY
8、),麻疹引起的间质性肺炎为Hecht巨细胞肺炎 (Interstitial pneumonitis resulting from measles virus takes the form of Hecht giant cell pneumonia),10/6/2018,麻疹,14,病理(PATHOGEY),麻疹皮疹的病理改变：真皮毛细血管内皮增生、血浆渗出、红细胞相对增多形成淡红色斑丘疹(Maculopapular rash consists of proliferation of capillary endothelial cells in skin,serous exudate and r
9、elative increase of red cells) 疹退后，表皮细胞坏死、角化形成脱屑。 皮疹处红细胞裂解，疹退后形成棕色色素沉着。,10/6/2018,麻疹,15,典型麻疹(Typical measles),潜伏期(Incubation stage) 一般为1014天(亦可短至1周)，此期可有轻度体温上升(It lasts usually 1014 days after contact,maybe as short as 1 week.The temperature may increased slightly)。,临床表现,10/6/2018,麻疹,16,典型麻疹,前驱期 (Pr
10、odromal stage)指从发热至出疹,一般为3-4天(from fever to rash appearance,usually lasts 3-4 days),临床表现,10/6/2018,麻疹,17,典型麻疹,主要表现：发热、上呼吸道炎症、眼结合膜炎、Stimson线(fever,upper respiratory inflammation, conjunctivitis ) 麻疹粘膜斑(Kopliks spots),前驱期 (Prodromal stage),临床表现,10/6/2018,麻疹,18,Kopliks spots (麻疹粘膜斑),时间：发疹前24 48小时出现(24-
11、48 hours before the appearance of the rash)； 位置：开始对着下臼齿的颊粘膜上；以后累及整个颊部并蔓延至唇部粘膜(initially opposite the lower molars but may spread the rest of the buccal and lip mucosa)。,临床表现,10/6/2018,麻疹,19,Kopliks spots (麻疹粘膜斑),形态：直径约1的灰白色小点，外有红晕(grayish white dots with 1mm in diameter,usually as small as grains of
12、 sand,that reddish areolae)； 发展：1天内很快增多，皮疹出现后逐渐消失(They spread rapidly within one day and disappear gradually after the appearance of the rash)。,临床表现,10/6/2018,麻疹,20,10/6/2018,麻疹,21,典型麻疹,出疹期 (eruption stage) 在发热3-5天后出现,持续3-5天出疹顺序:耳后、发际额、面部颈躯干四肢,达手掌、足底 (initially occurring behind the ears and hairline
13、 and spreading down from the forehead and faceto neck ,the trunk and the extremities).,临床表现,10/6/2018,麻疹,22,典型麻疹,出疹期 (eruption stage) 皮疹性质:红色斑丘疹，疹间皮肤正常(red maculupapular rash, there is normal skin among rashes.),临床表现,10/6/2018,麻疹,23,10/6/2018,麻疹,24,典型麻疹,恢复期 (convalescent period) 皮疹按出疹先后顺序消退,伴有糠麸样脱屑及
14、棕色色素沉着,经710天消失(The rash fades downward in the same sequence in which it appeared .As the rash fades , branny desquamation and brownish discoloration occur and then disappear within 7-10 days),临床表现,10/6/2018,麻疹,25,并发症(complications),肺炎(pneumonia) 是麻疹常见的并发症，多见于出疹期，继发细菌或其它病毒感染 喉、气管、支气管炎(laryngitis,trac
15、hitis, bronchitis) 心肌炎(myocarditis),10/6/2018,麻疹,26,并发症(complications),麻疹脑炎及亚急性硬化性全脑炎（measles encephalitis and subacute sclerosing panencephalitis 简称SSPE) 结核病恶化(tuberculosis exacerbating) 营养障碍与维生素A缺乏症(malnutrition and vitamin A deficiency),10/6/2018,麻疹,27,诊 断(DIAGNOSIS),麻疹接触史(exposure to measles pre
16、viously) 典型临床表现(typical clinical manifestations),10/6/2018,麻疹,28,诊 断(DIAGNOSIS),前驱期鼻咽部找多核巨细胞及尿中检测包涵体细胞(During the prodromal stage, multinucleated giant cells are found in nasopharynx,intrancuclear and intracytoplasmic inclusion bodies cells are found in urine),10/6/2018,麻疹,29,诊 断(DIAGNOSIS),ELISA法检测
17、麻疹抗体(Measles virus antibodies become detectable by ELISA when the rash ppears;testing of acute and convalescent sera shows the diagnostic seroconversion or fourfold increase in titer),10/6/2018,麻疹,30,鉴别诊断,10/6/2018,麻疹,31,麻疹的流行病学及预防,10/6/2018,麻疹,32,麻疹的流行病学及预防,流行病学传播途径： 主要是呼吸道飞沫传播。,预 防切断传播途径：实行“三门”，病人
18、住所、衣物按规定消毒。,10/6/2018,麻疹,33,麻疹的流行病学及预防,流行病学,预 防 保护易感人群：主动免疫(active immunization)，被动免疫(passive immunization)。,易感性:人类对麻疹病毒普遍易感。 易感者：未曾患过麻疹或未接种过麻疹疫苗者。,10/6/2018,麻疹,34,治 疗(TREATMENT),无特异抗病毒治疗，只有支持治疗和对症治疗。(There is no specific antiviral therapy ;treatment is entirely supportive and symptomatic treatment)
19、,10/6/2018,麻疹,35,治 疗,一般治疗 给予易消化的富有营养的食物，补充充足水分；保持皮肤、粘膜清洁,10/6/2018,麻疹,36,治 疗,一般治疗 卧床休息，房内保持适当的温度和湿度，有畏光症状时房内光线要柔和 (bed rest , keeping comfortably humidification and warm of the room ;patients with photophobia should be protected from exposure to strong light)。,10/6/2018,麻疹,37,治 疗,对症治疗 高热时可用小量退热剂。慎用退
20、热药，烦躁者镇静。剧咳时镇咳祛痰。继发细菌感染可给抗生素，补充维生素A。,10/6/2018,麻疹,38,麻疹的新进展,麻疹的发病年龄呈两极分化趋势婴儿麻疹增多，主要发生在8个月以前,多为非典型病例；大年龄患者增多。麻疹的不典型病例增多。发病高峰季节后移至3-5月份,10/6/2018,麻疹,39,麻疹的并发症的变化：心肌炎明显增多，且年龄越小，发病率越高。 二次麻疹发生率:在1%左右，其中60%发生在第一次麻疹二年以内。 虽然麻疹病例增多，但病死率却很低。,麻疹的新进展,10/6/2018,麻疹,40,麻疹前驱期最有诊断价值的表现 ( )A 发热3-5天 B 有卡他症状 C Kopliks
21、spots D 可见少数斑丘疹E 有麻疹接触史,麻疹提问1,10/6/2018,麻疹,41,麻疹提问2,麻疹最常见的并发症是：A 支气管肺炎 B 心肌炎 C 喉炎 D 脑炎和亚急性硬发性全脑炎 E 结核病恶化,10/6/2018,麻疹,42,麻疹提问3,6个月婴儿,突然体温升高达39.5以上已2天,一般情况良好,除轻微咽充血及颈、枕后淋巴结肿大外,未见其它异常.下列各项中最有可能的是( )A 如果继续发热48小时后出皮疹,考虑麻疹；B 这是风疹的前驱症状 ； C 如果继续发热2天，热退时全身出现皮疹,可考虑是幼儿急疹；D 要考虑猩红热,因本病多发生于6-18月小儿；E 以上都不是。,10/6/2018,麻疹,43,Thank you,
